435202714-9-5-2025-26-AS-MPAA-DL8T3J-20250905142225

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202714
Report Date: 09/05/2025
Date Signed: 09/05/2025 02:22:49 PM

Document Has Been Signed on 09/05/2025 02:22 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME:	ATRIA EVERGREEN VALLEY		FACILITY NUMBER:	435202714
ADMINISTRATOR/ DIRECTOR:	FELICIA R BARKLEY		FACILITY TYPE:	740
ADDRESS:	4463 SAN FELIPE ROAD		TELEPHONE:	(408) 532-7677
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95135
CAPACITY: 134		CENSUS: 87	DATE:	09/05/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Shay Arias and Beth Jennings		TIME VISIT/ INSPECTION COMPLETED:	02:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Maria (Mita) Partoza, conducted and unannounced Required 1-year inspection. LPA was met by Shay Arias Community Business Director and Beth Jennings - Life Guidance Director. Administrator Kris Waluszko was not present due to prior commitment at the time of the visit. The facility serves adults age 60 and over, 134 non-ambulatory, and delayed egress and hospice waiver for 13. LPA toured the interior of the facility, including entryway, common room, dining room, kitchen and food storage, laundry room, resident bedrooms, bathrooms, medicine room, and activities room, Assisted Living and Memory Care area of the facility. All emergency exits are clear from obstruction. Facility has activities scheduled posted for the whole month. LPA observed residents participating during activity time. The water temperature measured from 105 to 120 degree F. Memory Care exits are equipped with delayed egress and working audible alarms. The kitchen is equipped with commercial grade refrigerator and freezer and doors to the kitchen have locks when not in used and are not accessible to residents. The facility has emergency drinking water supply, 2 days of perishable food and 7 days for non-perishable food. The facility has snack bars in the activity areas. The facility is equipped with fire alarm and carbon monoxide alarm system that alerts the fire department. The residents room have sufficient and ample storage for the assisted living. Rooms in the assisted living were observed to be sanitary and organized. page 1 of 2 see LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/05/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: ATRIA EVERGREEN VALLEY	FACILITY NUMBER: 435202714
	VISIT DATE: 09/05/2025

NARRATIVE

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The facility has fire and disaster drill training that was administered on 7/17/2025. Fire extinguishers strategically placed in each floor and the kitchen. The facility is equipped with smoke alarm and water sprinklers. The fire extinguishers were consistently checked and maintained.

The medication room is locked are accessed by authorized employees, the room is not accessible to residents and unauthorized staff. Medications records are updated, reports are made in a timely manner.

Residents were observed engaging in activities in the game room, some are outside walking and resting outdoor by the courtyard and some of the residents joined the group for an outing. The memory care unit has 2 residents that were tested positive for Covid 19, LPA was not able to tour the Memory Care Area of the facility.

LPA reviewed 5 resident records and 5 staff record. LPA was able to verify that 5 Out of 5 Resident records are complete and updated. 5 Out of 5 staff record, have current First Aid/CPR certificates and have are background and fingerprint cleared by the Department. Staff training were updated according to their current positions. LPA requested the following for updated information: Admission Agreement, Dementia Care Plan, Liability Insurance, LIC 500 (personnel report), LIC 400, Surety Bond and LIC 308 and submitted to LPA by 09/09/2025.

No deficiency was cited during today's annual required visit. An exit interview was conducted with Life Guidance Director (LGD) Beth Jennings and a copy of the report was provided.

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End of Report

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/05/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2025

LIC809 (FAS) - (06/04)

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